Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend adding low-dose Aspirin for primary prevention in patients with Type 2 Diabetes on Eliquis for another indication?
Most guidelines and standards of care do not generally recommend aspirin therapy for primary prevention in patients with type 2 diabetes. As such, I do not generally recommend it unless their 10-year ASCVD risk is > 20% then I would have a discussion with the patient about low-dose (81 mg) aspirin t...
How would you approach management of a young male patient with discoid lupus who has had minimal response to hydroxychloroquine (and subtherapeutic whole blood levels) who continues to use tobacco products?
First, is he taking his HCQ (55% chance he is not)? Check a trough whole blood HCQ drug level and you want it to be 1000 - 1200 ng/mL (that is my goal in uncontrolled lupus; 750 - 1200 is fine in lupus under remission per Garg et al., PMID 37667434). Thanks, @Dr. First Last for reminding me. :-) Wh...
Do you find HZV titers useful in diagnosing shingles sine herpete?
VZV sine herpete is an infection/disorder frequently considered but rarely confirmed and represents an atypical presentation of VZV reactivation in the cranial nerve, spinal nerve, viscera, or CNS in the absence of classic cutaneous findings.Serum IgG VZV in isolation is not useful unless followed s...
How would you manage superficial thrombophlebitis of the great saphenous vein involving the knee and calf?
I would point you to an excellent algorithm created by Sherry Scovell on UpToDate, "Superficial Vein Thrombosis and Phlebitis of the Lower Extremity Veins" which has informed my practice. The highlights of the approach utilized are to perform imaging with Doppler ultrasound to determine the length o...
How long can you continue chronic low dose isotretinoin for refractory acne or other conditions?
No limit.
Can you explain the block and replace approach in the treatment of thyrotoxicosis, including when it is most appropriate to use and how it compares to other treatment options?
More than 20 years ago, Japanese researchers had data that suggest that remission rates for Graves' disease was much better with the block and replacement treatment with Methimazole/carbimazole and Levothyroxine. At least 3 US and European studies did NOT confirm this observation. I do occasionally ...
What is your approach to work up for patients referred for early onset osteoarthritis?
Great question and one that comes up fairly often. I created a mnemonic for causes of "secondary osteoarthritis" & these etiologies drive the workup - this might be appropriate for a person with OA in an unusual place or who is unusually young for having it. Here it is: THE CHARMING T- trauma H - ...
Do you avoid hyaluronic acid injections in patients with chondrocalcinosis on imaging?
The association between viscosupplementation and CPPD flares is reported but not truly well studied. There is a nice case series by Bernardeau et al., PMID 11302877 entitled “Acute arthritis after intra-articular hyaluronate injection: onset of effusions without crystals” in Ann Rheum Dis 2001;60:51...
What treatment do you use for stroke prevention in cervical artery dissection?
Two prior RCTs (CADISS and TREAT-CAD) investigated this topic, each with distinct designs. The CADISS trial found no statistically significant difference in primary outcomes between antiplatelet and anticoagulation therapy for extra-cranial dissection. However, the TREAT-CAD trial failed to demon...
What is your approach to treating patients with melasma that does not respond to hydroquinone-based topical therapies?
This is my Melasma algorithm: Hydroquinone triple cream qhs x 6 months + azelaic acid in the AM + tinted sunscreen Consider PO TXA (half of 650 mg tab bid), polypodium leucotomos bid (heliocare) Maintenance: stop hydroquinone and switch to compounded TXA/kojic/tretinoin combo cream qhs + vitamin C/...